venous dz Flashcards
risk factors for venous dz
o Prior ulcers o Smoking o Oral contraceptives/estrogen replacement o Genetics o Obesity o DVT " destined to have venous dz o Trauma o Prolong standing o Pregnancy o Advancing age
CEAP stands for
clinical
etiology
anatomy
pathophysiology
etiology categories
o c = congenital (i.e. Klippel Trenaunay syndrome)
o p = primary (i.e. valve degeneration)
o s = secondary (i.e. post-thrombotic/trauma)
clinical classification
o 0 = no signs of dz o 1 = telangiectasia/reticular eins o 2 = varicose veins o 3 = edema o 4 = pigment/eczema o 5 = healed venous ulcer o 6 = ac ive venous ulcer
anatomy classification
o s = superficial
o p = perforator
o d = deep veins
” P = Pathophysiology: classification
o r = reflex
o o = obstruction
o r, o = reflux & obstruction
Subdermal and intradermal
Up to 50% of population W>M
Reticular veins (spider veins) and telangiectasias
3mm or greater in diameter
Up to 30% of population
Varicose veins
Chronic venous insufficiency
Edema and ulceration
Up to 7 million affected
Superficial veins are superficial to _________
Superficial veins are superficial to the deep muscular fascia
Deep veins are deep to the _______and are either within the ______or between them
Deep veins are deep to the muscular fascia and are either within the muscle or between them
The perforating veins communicate between the ______ and______
The perforating veins communicate between the superficial and the deep venous systems
Superficial venous systemlower extremity
GSV great saphenous vein and small saphenous vein
GSV sometimes is duplicated in the thigh or calf
Popliteal vein becomes the _____ in the______
Popliteal vein becomes the femoral vein in the adductor canal
Profunda femoris vein drains _______ and joins with the ______to become the common femoral vein in the groin
Profunda femoris vein drains lateral thigh muscles and joins with the femoral vein to become the common femoral vein in the groin
these veins connect the superficial with the deep veins (direct perforators)
Perforating veins
Venous _______ are thin-walled and valveless
Located in the calf musculature
Venous sinuses are thin-walled and valveless
Located in the calf musculature
Normal standing pressures are
Normal standing pressures are 90-100mmHg
Calf pump reduces venous pressures by over ____within 10 steps
Calf pump reduces venous pressures by over 70% within 10 steps
Recovery refill after exercises is about ____
Recovery refill after exercises is about 20-70s
Normal displacement _____ of venous blood within the leg to the popliteal vein with each contraction
Normal displacement >60% of venous blood within the leg to the popliteal vein with each contraction
Prolonged hypertension=“
Prolonged hypertension=“leaky capillaries” RBC’s and macromolecules leak, causing inflammatory response into interstitial space Matrix metalloproteinases (MMP’s) and cytokines released which cause tissue fibrosis which impair healing
Patients with superficial venous insufficiency may only be able to reduce pressure by ____
Patients with superficial venous insufficiency may only be able to reduce pressure by 30-40%
Deep venous insufficiency reduction____ with very fast calf refill
Deep venous insufficiency reduction <20% with very fast calf refill
Diagnosing venous diseasePatient history typical sxs
Heaviness, fatigue, pain, itching
Chronic iliofemoral obstruction can result in venous claudication—thigh pain and feeling of tightness with exercise
Leg symptoms are more common in chronic obstruction than in those who have recanalized and have incompetent valves
clinical presentation of venous disease
- – +/- obvious venous bulges
- sx may not correlate well w/ the amount of defect
- Abrasion can lead to impressive bleeding
- Superficial thrombophlebitis relatively common –> can be painful –> rarely leads to PE
- Edema
- Lipodermatosclerosis
- Hyperpigmentation (hemosiderin staining)
- Absence of hair (also seen in PVD)
- Thickened nails
- Varicosities
- Blistering/bullae
Signs of venous insufficiency
Edema Lipodermatosclerosis Hyperpigmentation (hemosiderin staining) Absence of hair (also seen in PVD) Thickened nails Varicosities Blistering/bullae
- Lipodermatosclerosis
hardened skin that can develop with chronic venous insufficiency
Hypoxia in subcutaneous fat
—>hard “woody” induration starts at ankles & progresses proximally
Lipodermatosclerosis
Lipodermatosclerosis presents like a
Inverted champagne bottle or bowling pin appearance
tx for Lipodermatosclerosis
” Avoid BX! í poor healing
“ Stanozol-anabolic steroid w/ fibrinolytic properties helps w/ pain, inflammation & pigmentation
“ Vicki says she does not use this
Hemosiderin Staining
” Valves fail—->regurgitated blood (& venous HTN) force RBC to leak from capillaries
Hemosiderin Staining need to differentiate from
cellulitis
not hot and does not extend
does nothing with abx
venous vs arterial ulcer?
CM of VLU
Generally irregularly shaped, well-defined borders surrounded by erythematous or hyper-pigmented indurated skin
usually found on the ankles
Yellow-white exudate common
Located on lower 1/3 of leg above ankle, MC at medial malleolus —>”gaiter distribution”
NEVER found above the knee & rarely on the foot
Varicose veins & ankle edema are common
physical exam for VLU
Check pedal pulses
ABI (ankle-brachial index test) < 0.70 í consult vascular specialist
Test determined by recording segmental limb pressures
ABI
Normally, ankle pressure should be slightly higher, resulting in an ABI of 1.0 or greater
PVD or PAD indicated if ABI is less than 1.0 (the lower the ABI, the move severe the dz)
arterial ulcers
punched out, well defined, usually on the feet
ABI (ankle-branchial index test) what is it and how do we calculate
allows you to determine where the diseases is
Test determined by recording segmental limb pressures
if less than .70 need to consult vascular
is calculated by dividing the SBP in the ankle by the SBP in the brachial artery in the arm
Normally, ankle pressure should be…
Normally, ankle pressure should be slightly higher, resulting in an ABI of 1.0 or greater
what is indicated with a ABI <1.0
PVD or PAD indicated if ABI is less than 1.0 (the lower the ABI, the move severe the dz)
DDX of VLU
Untreated CHF Lymphedema Arterial dz: ABI Cellulitis: is it hot? DVT: SCC: skin cancer on LE?
Invasive & expensive but GOLD standard for dx VLU
CT &MR venography
CT &MR venography, when do we use
invasive & expensive but GOLD standard
Useful for evaluating central veins which are hard to assess w/ US
Reserved for those needing reconstruction
Anatomic abnormalities - no use in physiologic evaluation
Non-invasive, inexpensive & very reliable (MC used as 1st line fo dx VLU)
2) Duplex US
Venous plethysmography for dx
Pulse volume recorder that’s attached to a blood pressure cuff (or other sensors) –> measures ∆s in the volume of a limb or extremity
Helps ID or rule out blood clot in a calf vein (i.e. DVT)
Also helps ID dysfunction of important valves
mainstay therapy for VLU/dz
Compression therapy (to ↓ venous HTN)
tx if they don’t have a ulcer but have venous dz
Elevate
Walk –> improves calf pump
Lose weight
Avoid prolonged standing or sitting
Maintain skin integrity
Debride a VLU
once a week to manage bacteria
TX for VLU
control exudate debride VNUS Pentroxifylline prevent reoccurrence
VNUS now venefit
Radiofrequency ablation energy is applied to the inside of vein walls of a damaged vessel í as RF energy is delivered and the catheter is withdrawn through the damaged vein, the vein wall heats up í causes wall to shrink and vein to close
When do you culture VFU
Culturing wound is not indicated unless infection is suspected
Iodosorb, silvadene, medi-honey and hyperbaric chambers for VLU?
Iodosorb, Silvadene and medi-honey have not been proven to be effective
Hyperbaric treatment has not been shown to be effective
Pneumatic compression, electromagnetic therapy also not helpful
Types of compression for venous dz
Compression stocking (no ulcer)
Multilayer (Profore) (ulcer)
Unna’s boot (ulcer and mobile)
Circaids (post healing)
Compression stocking
how does it work and what are the advantages/disadvantages?
don’t use for ulcer
only after healed
Difficult to put on especially for elderly or mobility impaired í Butler, gloves available to assist donning
20-30 mmHg compression needed
Replace q3-6mos
Gently wash - line dry
what to check before implementing compression tx
need to check blood flow
make sure it’s not arterial dz if so send to a specialist
CHF: need water off
neuropathy: if they can’t feel anything you could have a new wound with compressions
active cellulitis: tx this 1st
expected outcomes
need to respond well (40%) in 4 weeks –> high incidence of closure at 12 weeks
those that don’t respond well are unlikely to heal and need to be reevaluated
60-70% of ulcers closed after 3-6 months of treatment
recurrence rate of 25% within a year
aggressive ulcerating SCC presenting in an area of previously traumatized, chronically inflamed or scarred skin
” Marjolin’s ulcer
what do you need to for a suspected vasculitis
biopsy
responds to prednisone
what do you need to do if you suspect a arterial insufficiency
Doppler US/ABI
Profore (multilayer) layers
used for active ulcer
1st layer: cotton wrap for comfort but can use acrylics
2nd layer: comformable bandage
3rd layer: light compression bandage
“
4th layer: flexible cohesive bandage
“
Offers graduated compression
Change q 1wk
50% stretch 50% coverage of previous layer
why should you never use ACE wrap for compression therapy
calf sausage
these aren’t made for venous insufficiency
Unna’s boot
what are the pt requirement
very good fo venous ulcers and dry skin
Pt must be mobile
+/- calamine/zinc oxide (topical lotion used to relieve skin pain, itching, discomfort, oozing)
Spiral wrap –> start at base of toes and work toward tibial
No wrinkles, no tension
Cover w/ coban dressing - 50% tension
Cover w/ stockinette if possible
when do you need to replace compression stocking
Replace q3-6mos
Circaids
Inelastic compression garment w/ Velcro strapping system
Once VLU healed –>goes on during AM, off QHS
Great for: pt who can’t reach feet, neuropathic, lymphedema
Machine washable
Usable up to 6m-18m
How to measure for Circaids
Popliteal fossa to floor (length: short/long)
Widest part of calf
Ankle around malleoli
Arch of foot
Patients MUST be instructed on donning appropriately after receiving them
You can become a Circaid certified fitter
Care for Circaids
Most can be machine washed (in garment bag) on gentle cycle and either drip dried or machine dried on low setting
Usage varies 6m-18m depending on type
after healing a VLU how do you make sure a ulcer does not return
circaids, stockings or venous ablation
venefit/VNUS efficacy
93% Closure at 3 years
before referring for venefit you need a
US to check for reflux
Differences between RFA and laser
RFA uses radiofrequency at 20 second intervals which destroys the collagen within the wall of the vein. This causes collapse and shrinkage of the vein thus occlusion
Laser uses heat at variable frequencies also targeted at the vein wall. Can puncture the wall. Causes clot formation within the vessel
Sclerotherapy
in office 3% hypertonic solution
damages the vein and closes it off
saphenous vein greater potential of nerve injury if stripping down to ankle
Vein stripping
Term used to describe venous inflammation even when it is unclear whether thrombosis of the vein has occurred.
Thrombophlebitis
Indicates presence of a clot
Thrombosis
Inflammation of the vein
Phlebitis
May-Thurner syndrome
what is it and how do you treat it
Compression of L CIV by the R CIA
Often asymptomatic, as many as 20% of population affected, but only a small fraction have symptoms of edema, leg asymmetry or thrombosis
Treat with angioplasty/stent
Lower extremity superficial phlebitis is common or rare?
Lower extremity superficial phlebitis is rather common.
EpidemiologyPhlebitis
Estimated that 3-11% of population affected
More common in varicose veins
Patients w/o varicose veins also affected 5-10%
Virchow’s triad
Stasis
Hypercoaguable state
Vein injury
CM of plebitis
Pain, warmth, redness, may feel a cord
Can resemble cellulitis, lymphangitis
dx plebitis
Confirm w/US and or D-Dimer
Low clinical suspicion and normal D-Dimer has negative predictive value of greater than 99% so US not warranted
Treatment of phlebitis
Mostly supportive as superficial phlebitis is not life threatening and will resolve on it’s own in a few weeks.
compression and elevation
Schedule a follow up appointment in 7-10 days to reassess your patient
Topical diclofenac may be helpful for pain. warfarin not helpful
dx Thrombosis
Homan’s sign 56% sensitivity 39% specific
Get an ultrasound to determine location and extent (highly sensitive 90-100% in fem-pop, less so in calf 60-90%)
types of thrombosis
Clot formation following inflammation
Deep vs superficial
when would you treat thrombosis with medication
those at higher risk for DVT, and those whose thrombosis is >5cm or <5cm from the deep system should be considered for anticoagulation therapy for at least 4 weeks.
thrombosis high risk
High risk of recurrance, consider surgical intervention
Deep vein thrombosis looking for
History-Virchow’s triad Exam-not very specific Labs/testing-US/D-dimer Well’s score Treatment and for how long
Cerulea seen as the CM
Cerulea-blue discoloration
emergent (risk of gangrene)
Phlegmasia alba dolens
doesn’t affect collateral veins and there is no ischemia
higher incidence in third trimester post partum
Involves the collateral veins
Increased congestion
Affects arterial flow
Risk of gangrene
Cerulea
____ of those patients who have had a DVT will develop venous insufficiency signs after 5-10 years.
80% of those patients who have had a DVT will develop venous insufficiency signs after 5-10 years.
Postphlebitic syndrome is found in all patients ______after a DVT. Leg discomfort and edema
Postphlebitic syndrome is found in all patients 1-2 years after a DVT. Leg discomfort and edema
anticoagulation
Goal is to_____the propagation of thrombus or embolism to the pulmonary circulation.
Goal is to prevent the propagation of thrombus or embolism to the pulmonary circulation. It does not dissolve the present clot but allows the fibrinolytic system to eliminate it over time
when do you admit a pt?
Iliofemoral DVT
PE (of course!)
Co-morbidities warrant it
High risk of bleeding (anticoagulation contraindicated)
Absolute contraindications to anticoagulation
Active bleeding
●Severe bleeding diathesis
●Platelet count <50,000/microL
●Recent, planned, or emergent surgery/procedure
●Major trauma
●History of intracranial hemorrhage
●History of heparin-induced thrombocytopenia
Relative contraindications to anticoagulation
Recurrent bleeding from multiple gastrointestinal telangiectasias
●Intracranial or spinal tumors
●Platelet count <150,000/microL
●Large abdominal aortic aneurysm with concurrent severe hypertension
●Stable aortic dissection
What does a primary care provider do?
Send them to surgery for in IVC filter
These usually tend to stay in indefinitely as the risk of removal and thus damaging the vessel rarely outweighs any risk of leaving it in place.
Anticoagulation therapy duration
Minimal 3 months if first DVT and unprovoked-this can and often is extended
If 1st DVT by provoked reversible event (ie surgery) or patient at high risk for bleeding then tx duration is
If 1st DVT by provoked reversible event (ie surgery) or patient at high risk for bleeding then 3 month treatment is usually NOT extended
when is a DVT high risk for indefinite
Recurrent 6-12 months
High risk for recurrent DVT indefinite
” May-Thurner Syndrome (MTS)
aka Iliac Vein Compression Syndrome
o Rare condition in which DVT occurs in the iliofemoral vein OR when the R CIA compresses the L CIV
o Often asx
o Small fraction have sx of: edema, leg asymmetry, thrombosis
” Homan’s sign
+ for DVT if discomfort behind the knee on forced dorsiflexion of the foot
DVT CM
virchows
unilateral swelling
calf pain (50%) homan’s sign
palpable cord
first line test for DVT
venous duplex ULS
what can you do to rule out DVT in low risk pt
D dimer
what is the gold standard for DVT diagnosis
venography
DVT tx length
If 1st DVT and unprovoked: 3 mo
“ 2) If recurrent: 6-12 mo
“ 3) If high risk for recurrent DVT: indefinite
Kippel-Trenaunay Syndrome Triad
1) Capillary hemangioma (port wine stain)
2) Limb hypertrophy (edema)
3) Varicose veins
